Criteria
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Behandeling acuut coronair syndroom in een urgente situatie (in afwachting van hospitalisatie)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022La prise en charge du syndrome coronarien aigu (SCA) en situation d'urgence (en attente d'hospilatisation)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022Diagnosis
Criteria required to meet the definition for acute myocardial infarction (MI) (types 1, 2, and 3 - see Classification) include:[3]
Acute myocardial injury with clinical evidence of acute myocardial ischaemia and with detection of a rise and/or fall of cardiac troponin values with at least one value above the 99th percentile upper reference limit (URL) and at least one of the following:
Ischaemic symptoms
New, or presumed new, ECG changes indicative of ischaemia (left bundle branch block, ST elevation or depression)
Development of pathological Q waves on the ECG
Myocardial necrosis or regional wall motion abnormality evidenced by cardiac imaging
Intra-coronary thrombus detected on angiography or autopsy.
Pathological findings of an acute MI.
The term 'myocardial injury' is used when there is evidence of elevated cardiac troponin values with at least one value above the 99th percentile URL.[3] The myocardial injury is considered acute if there is a rise and/or fall of cardiac troponin values.[3]
Acute coronary syndrome (ACS) is a term used to describe a range of conditions resulting from sudden reduction in coronary blood flow. Symptoms should be present suggestive of angina or anginal equivalent presentation. The presence or absence of ST-segment elevation on presenting ECG indicates ST-elevation MI (STEMI), or non-ST-elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS is further sub-divided into NSTEMI or unstable angina, depending on elevation of troponin.
STEMI: ECG demonstrates ST elevation of >1 mm in ≥2 anatomically contiguous leads, usually associated by location. Repolarisation abnormalities often evolve over time from hyperacute T waves to ST elevation to T-wave inversion to the development of Q waves. STEMI patients typically have a rise and fall of serum cardiac biomarkers. While biomarkers are useful for confirmatory and prognostic purposes, they are not required for the diagnosis of STEMI and should not delay treatment. Clinicians must be careful to recognise other causes of ST elevation that mimic a STEMI. These include left ventricular hypertrophy, left bundle-branch block, paced rhythm, benign early repolarisation, pericarditis, and hyperkalaemia.
NSTEMI: ECG does not show persistent ST elevation, but may show ischaemic changes such as transient ST elevation, ST depression, or T-wave changes.[5] The ECG may also be normal. Serum levels of cardiac biomarkers are elevated.
Unstable angina pectoris: cardiac biomarkers are normal.[5]
Risk assessment
ACS diagnosis and management requires continuous risk stratification for death or recurrent MI. The UK National Institute for Health and Care Excellence (NICE) recommends the following:[72]
A full clinical history (including age, previous MI, and previous percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG])
A physical examination (including measurement of blood pressure and heart rate)
A resting 12-lead ECG, looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia
Blood tests (such as Troponin I or T, creatinine, glucose, and haemoglobin)
A validated risk scoring system that predicts 6-month mortality (e.g., Global Registry of Acute Cardiac Events [GRACE]). See further details of risk scoring systems below.
Global Registry of Acute Coronary Events (GRACE) risk score
NICE recommends using the GRACE risk score to predict 6-month mortality in patients following an initial ACS to guide further management decisions about invasive coronary angiography +/- revascularisation. Use predicted 6-month mortality to categorise the patient’s risk of future adverse cardiac events as follows:
Predicted 6-month mortality | Risk of future adverse cardiac events |
|---|---|
≤1.5% | Lowest |
>1.5-3.0% | Low |
>3.0-6.0% | Intermediate |
>6.0-9.0% | High |
>9.0% | Highest |
[ GRACE Score for Acute Coronary Syndrome Prognosis Opens in new window ]
Thrombolysis in Myocardial Infarction (TIMI) risk score[112]
All-cause mortality, rate of MI, and rate of revascularisation at 14 days increase in proportion to the number of risk factors present on the TIMI score. One point is awarded for the presence of each of the following criteria (patients with a score of 0 to 2 are low risk, 3 to 4 are intermediate risk, and 5 to 7 are high risk):
Age >65 years
Presence of ≥3 coronary artery disease risk factors
Prior coronary stenosis >50%
ST-segment deviation on ECG
Elevated serum cardiac biomarkers
At least 2 anginal episodes in the past 24 hours
Use of aspirin in the past 7 days.
Killip Classification
The Killip classification risk stratifies patients with acute MI based on clinical evidence of left ventricular failure.
Class I: no evidence of congestive heart failure
Class II: presence of a third heart sound gallop, basilar rales, or elevated jugular venous pressure
Class III: presence of pulmonary oedema
Class IV: cardiogenic shock.
HEART Score
Incorporates elements of the patient's history, ECG, age, risk factors, and troponin and is used for patients in the accident and emergency department setting to assess risk of acute MI, percutaneous intervention, coronary artery bypass graft, and death within 6 weeks of initial presentation.
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